The findings of the re-licensure survey, conducted 03/18/24 through 03/19/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/19/24, conducted 08/05/24 through 08/06/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction for staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 02/14/24, and progress notes from 12/2023 to 03/2024 were completed.

Staff indicated the resident had increased weakness. The resident had poor safety awareness and tried to get up on his/her own, resulting in falls. The staff further indicated they provided assistance with ADLs and two person assistance with transfers. The resident's service plan was not reflective and lacked resident specific direction in the following areas:

* Falls and safety interventions;

* Walker use for mobility and transfers;

* Number and level of staff assistance required and specific steps for ADL completion;

* Behaviors, including aggression, and agitation; and

* One-person versus two-person transfers and devices used;

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 03/18/24 and 03/19/24. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2018 with diagnoses including dementia. Resident 2 was receiving hospice service.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/11/24, progress notes from 12/2023 to 03/2024, and hospice communication were completed.

Staff indicated they provided full assistance with all ADLs and two person assistance with transfers. The resident's service plan was not reflective and lacked resident specific direction in the following areas:

* Mobility level and ability of the resident;

* Use of pressure devise and foot rests in wheelchair;

* Number and level of staff assistance required and specific steps for ADL completion; and

* One-person versus two-person transfers

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 03/18/24 and 03/19/24. She acknowledged the findings.

Bartlett House of Medford will implement the following:

1. Service Plans for Residents 1 and 2, and all Service Plans have been reviewed and updated to meet all residents' needs.

* Falls and safety interventions;

* Walker use for mobility and transfers;

* Number and level of staff assistance

required and specific steps for ADL

completion;

* Behaviors, including aggression, and

agitation; and

*Transfers One-person versus two-person

transfers and devices used.

* Mobility level and ability of the resident;

* Use of pressure devise and foot rests

in a wheelchair.

* Resident service

plans are reflective of current care

needs and provided with clear direction.

2. The Executive Director will be double checking all care plans after Nurse, Assistant and caregivers have done any changes or updated on care plans to be sure they meet the residents needs.

3. Care Plans will be reviewed by the whole team before completed and printed each and every time Executive Director, Assistant, care staff and Nurse.

4. The Executive Director will be responsible for monitoring and be sure all service plans are completed

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition were monitored at least weekly to resolution, and that interventions were re-evaluated to determine effectiveness for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition.

1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 02/14/24, incident investigations, and progress notes dated 12/2023 through 03/2024 were reviewed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Falls;

* Behaviors;

* Acute illness and hospital stay; and

* Wounds and injuries.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and that interventions were evaluated for effectiveness related to falls and behaviors was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Universal Worker/RCC) on 03/19/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2018 with diagnoses including dementia and was receiving hospice services.

Observations of the resident, interviews with staff, review of the service plan dated 01/11/24, hospice communications, and progress notes dated 12/2023 through 03/2024 were reviewed.

a. The resident experienced short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Bruising; and

* Injuries to hands caused by resident finger nails.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with  Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Universal Worker/RCC) on 03/19/24. They acknowledged the findings.

Bartlett House of Medford will implement the following:

1.Residents 1 and 2 and all Residents will be placed on alert charting for any changes in condition, medications or incidents. Monitoring will continue each shift until resolved and closed by the Executive Director or nurse. Any COC needed and observed will be reported and put on the nursing communication board in pcc and communicated with the nurse.?

2.Executive Director and assistant Executive Director will both check alert charting for correct opening documentation on incidents and change of conditions and monitoring. The Executive Director and Nurse will close alerts when resolved.

3.The Executive Director and Assistant Executive Director will check at least 3 times a week that staff are completing alert charting each shift.

The Executive Director and Assistant Executive Director will be responsible to see that corrections are complete and monitored.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#1) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

Resident 1 had a physician's order for Quietiapine 25 mg as needed for  agitation and impulsivity.

Resident 1's 2/2024 and 03/2024 MARs were reviewed. The resident was administered the psychotropic medication three times in 02/2024 and twice in 03/2024 with no documented evidence staff had first attempted non-drug interventions with ineffective results.

The need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

Bartlett House of Medford will implement the following:

1.Correct interventions will be placed in EMAR for staff to sign and in care plan with detailed steps to try before use of behavioral medication for Resident 1.

2.  Staff will be retrained on correct documentation with use of medication, will be sure one hour follow up is completed with effective or ineffective and to document the result of effectiveness.

3. Executive Director and Rn Assistant Executive Director and Nurse will review weekly for PRN use to ensure it is being used correctly and documentation is correct.

4.Executive Director And Assistant Executive Director will be responsible for weekly monitoring of PRN use and put use in Nurse corner for review.

Based on observation, interview, and record review, it was determined the facility failed to ensure Acuity Based Staffing Tool (ABST) entries were reflective of the resident's current care needs for 3 of 3 sampled residents reviewed (#s 1, 2, and 3). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2023 with diagnoses dementia with behaviors.

Observations of the resident, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 1's ABST revealed an inaccuracy of minutes assigned in the following areas:

* Bowel and bladder management;

* Assisting with leisure activities;

* Monitoring behavioral conditions or symptoms;

* Ensuring non-drug interventions for behaviors;

* Redirecting due to cognitive impairment or dementia; and

* Medication administration, passing out medications.

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (Administrator) 03/19/24. She staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2018 with diagnoses dementia.

Observations of the resident, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 2's ABST revealed an inaccuracy of minutes assigned in the following areas:

* Medication administration, passing out medications;

* Transferring in or out of bed or a chair; and

* Supervising, cueing, or supporting while eating

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (Administrator) 03/19/24. She staff acknowledged the findings.  

3. Resident 3 was admitted to the facility in 02/2024 with diagnoses dementia and insulin dependent diabetes.

Interviews with staff and review of the resident's records noted ABST entries were not reflective of the resident's current care needs related to medication administration.

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (Administrator) on 03/19/24. She staff acknowledged the findings.

Bartlett House of Medford will implement the following:

1.Resident 1, 2,3, and all residents will be reviewed and the ABST tool will be updated with proper and reflective time for each task with the care plan and time it takes to provide the task per shift. Staff will be updated to requirements.

     2. The Executive Director will review each resident's services and ensure the ABST tool is up to date and reflective of the current plan of care. Staffing hours will be updated to meet the ABST tool requirements.

3. Initially, 30 days and quarterly and as needed.

4. The Assistant Executive Director and Executive Director will be responsible to ensure correction is completed and monitored.

Based on interview and record review, it was determined the facility failed to provide fire and life safety training at least every other month. Findings include, but are not limited to:

Fire and life safety records, reviewed between 05/2023 - 03/2024, revealed fire and life safety training was not documented as completed every other month alternating with fire drills.

On 03/18/24 and 03/19/24 the need provide fire and life safety training was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Bartlett House of Medford will implement the following:

      1.Fire Drills will be done every other month and    

      fire safety staff meetings will be every other month      

       during staff meetings.

1.The Executive Director and Assistant Executive Director  now have a fire training book to go over and train on every other month on fire topics.

    3.Executive Director will upload to drive after   

       safety meetings and fire drills every other month,

        Assistant will review every month to ensure  

        completion.

    4.The Executive Director and Assistant Executive  

       Direct will be responsible to ensure that bi monthly  

      drills and trainings are done and monitored for  

        completion.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 361 and C 420.

Refer to C420 and C361

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff (#s 4 and 5) completed 16 hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 03/18/24 and 03/19/24.

Staff 4 (Universal Worker), hired 09/25/20, and Staff 5 (Universal Worker) hired 06/13/19, lacked evidence of 16 hours of annual in-service training based on anniversary date of hire.

The need to ensure staff completed 16 hours of annual training, including six hours related to dementia care and annual infectious disease training was discussed with Staff 1 (Administrator) on 03/18/24 and 03/19/24. She acknowledged the findings.

Bartlett House of Medford will implement the

       following:

1.Staff 4 and 5 and all staff have the training needed for the year now per oars.

2.All staff are now aware that if they don't have the training assigned to them each month done by the end of each month, they will be taken off the schedule, and a yearly training sheet has been done to track each month's training.

3.This will be evaluated monthly

Executive Director is responsible to be sure this is completed

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260, C 270, and C 330.

Refer to C260, C270, and C330

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (#1) with documented behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

Resident 1's record documented behaviors including refusal of care, aggression with staff, and agitation.

The resident's service plan, dated 02/14/24, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 03/19/24, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator). She acknowledged the findings.

?????Bartlett House of Medford will implement the following:

1.Resident 1 and all residents have been assessed for behaviors and step by step instructions are in the service plan for staff to follow if there are any behaviors.

2.Anytime a new behavior happens, the Executive Director and RN will double check to be sure there are step by step instructions for staff.

3.Initial, 30 day, 90 day and change of conditions.

The Executive Director and RN will be responsible to see that corrections are completed and monitored.